Background 

Septic ankle arthritis is a devastating clinical problem with a high potential for permanent disability and amputation. Successful treatment of septic ankle arthritis remains a challenge for the surgeon and patient. Ankle arthrodesis combined with radical debridement may be an effective option to eradicate infection and salvage the limb. Although numerous fusion methods have been proposed, there is controversy about the most effective technique.

Questions/purposes 

At a minimum follow-up of 6 years after ankle arthrodesis performed using an Ilizarov external fixator, we asked, (1) In what proportion of patients was bony fusion achieved? (2) What complications were observed, and what reoperations were performed in these patients? (3) How much did patient-reported outcomes improve from before surgery to the most recent follow-up in this group?

Methods 

Between April 2010 to March 2015, we treated 59 patients for septic ankle arthritis. Of those, we considered patients who were at least 18 years of age with irreversible destruction of the joint as potentially eligible. During that time period, all patients met the prespecified criteria and were treated with ankle arthrodesis using an Ilizarov external fixator. Two percent (one of 59) of patients were excluded because they died in the second year after surgery for reasons unrelated to the procedure, and another 7% (four of 59) of patients were excluded because they were lost before the minimum study follow-up interval of 6 years. Finally, 92% (54 of 59) of patients were analyzed at a mean follow-up time of 9 ± 1 years. A total of 61% (33 of 54) were men, and they had a mean age of 48 ± 12 years. Forty-six percent (25 of 54) of patients were smokers, and 13% (seven of 54) of patients had Type 2 diabetes mellitus. All patients received radical debridement and primary arthrodesis with an Ilizarov external fixator, followed by antibiotic therapy. Postoperatively, patients were instructed to perform lower extremity functional exercises and external fixator care; weightbearing ambulation as tolerated was encouraged as early as possible. Fusion was assessed with a radiographic review that was performed by an individual who was not involved in the surgical care of these patients. We defined bony fusion as continuous trabeculae and complete cortical bridging in the fusion interface achieved before 9 months; delayed union was defined as fusion achieved by 9 to 12 months; and nonunion was defined as patients in whom fusion was not achieved by 12 months. Complications and reoperations were tallied through a record review that was performed by an individual who was not involved in the surgical care of these patients. We defined complications as any deviation from the expected postoperative course. We used the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the VAS active pain score, and the SF-12 questionnaire (including the physical component summary [PCS] score and mental component summary [MCS] score) to assess patient-reported outcomes. The minimum clinically important difference (MCID) for the AOFAS score was 30 points of 100, the MCID for the VAS active pain score was 2 points of 10, and the MCID of PCS and MCS scores was 7 points and 9 points, respectively.

Results 

Primary bony fusion was achieved in 94% (51 of 54) of patients. Delayed union was found in 2% (one of 54) of patients. Nonunion was found in 6% (three of 54); one of these patients underwent autologous bone grafting during revision, and bony fusion was ultimately achieved. Final bony fusion was achieved in 96% (52 of 54) of patients. Recurrent infection was found in 2% (one of 54). The median (range) AOFAS score improved from 28 points (8 to 59) before surgery to 80 points (52 to 86) at the most recent follow-up (median difference 52; p < 0.001). The median (range) VAS active pain score decreased from 8 points (6 to 9) before surgery to 2 points (0 to 5) at the most recent follow-up (median difference -6; p < 0.001). For the Short Form 12-item score, the median (range) PCS score improved from 0 points (0 to 30) before surgery to 70 points (40 to 95) at the most recent follow-up (median difference 70; p < 0.001), and the median (range) MCS score improved from 46 points (21 to 75) before surgery to 75 points (50 to 92) at the most recent follow-up (median difference 29; p < 0.001).

Conclusion 

Ankle arthrodesis with Ilizarov external fixation might eradicate an infection and restore foot function in patients with septic ankle arthritis. However, patients should be fully informed of the complications related to the external fixator, such as pin-tract infections, recurrent infection, and nonunion. Standardized and professional pin care is important. Additionally, because Ilizarov external fixators can be inconvenient to the patients’ daily lives, future studies should explore how psychologic support affects patients who undergo ankle arthrodesis with these devices.

Level of Evidence 

Level IV, therapeutic study.

中文翻译：

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使用 Ilizarov 外固定器进行踝关节固定术是治疗化脓性踝关节炎的有效方法吗？至少 6 年随访的研究

 背景

化脓性踝关节炎是一种毁灭性的临床问题，极有可能造成永久性残疾和截肢。成功治疗化脓性踝关节炎对于外科医生和患者来说仍然是一个挑战。踝关节融合术联合根治性清创可能是根除感染和挽救肢体的有效选择。尽管已经提出了多种融合方法，但对于最有效的技术仍存在争议。

 问题/目的

在使用 Ilizarov 外固定器进行踝关节融合术后至少 6 年的随访中，我们询问：（1）有多少比例的患者实现了骨融合？ （2）这些患者出现了哪些并发症，并进行了哪些再次手术？ (3) 从手术前到最近一次随访，该组患者报告的结果改善了多少？

 方法

2010年4月至2015年3月期间，我们治疗了59名化脓性踝关节炎患者。其中，我们认为年满 18 岁、关节受到不可逆破坏的患者可能符合资格。在此期间，所有患者均符合预先设定的标准，并使用 Ilizarov 外固定器接受踝关节融合术治疗。 2%（59 人中的 1 人）的患者被排除在外，因为他们在术后第二年因与手术无关的原因死亡，另外 7%（59 人中的 4 人）患者被排除在外，因为他们在最低研究随访时间之前就去世了。上涨间隔6年。最后，92%（59 名患者中的 54 名）的平均随访时间为 9 ± 1 年进行了分析。总共 61%（54 人中的 33 人）是男性，平均年龄为 48 ± 12 岁。 46%（54 名患者中的 25 名）的患者是吸烟者，13%（54 名患者中的 7 名）患有 2 型糖尿病。所有患者均接受根治性清创和使用 Ilizarov 外固定器进行初次关节融合术，然后接受抗生素治疗。术后指导患者进行下肢功能锻炼及外固定架护理；鼓励尽早进行可耐受的负重行走。通过放射线检查评估融合情况，该检查由未参与这些患者手术护理的个人进行。我们将骨性融合定义为9个月前在融合界面中实现连续的小梁和完整的皮质桥接；延迟愈合定义为 9 至 12 个月实现融合；骨不连定义为 12 个月内未实现融合的患者。 并发症和再次手术是通过记录审查来统计的，该记录审查是由未参与这些患者手术护理的个人进行的。我们将并发症定义为与预期术后过程的任何偏差。我们使用美国骨科足踝协会 (AOFAS) 踝-后足评分、VAS 主动疼痛评分和 SF-12 问卷（包括身体成分总结 [PCS] 评分和精神成分总结 [MCS] 评分）来评估患者报告的结果。 AOFAS 评分的最小临床重要差异（MCID）为 30 分（满分为 100），VAS 活动性疼痛评分的 MCID 为 2 分（满分为 10），PCS 和 MCS 评分的 MCID 分别为 7 分和 9 分。

 结果

94%（54 名患者中的 51 名）实现了初次骨融合。 2%（54 名患者中的一名）发现延迟愈合。 6% 的患者出现骨不连（54 例中的 3 例）；其中一名患者在翻修过程中接受了自体骨移植，最终实现了骨融合。 96%（54 名患者中的 52 名）实现了最终骨融合。 2% 的人发现复发感染（54 人中的 1 人）。 AOFAS 评分中位数（范围）从手术前的 28 分（8 至 59）提高到最近一次随访时的 80 分（52 至 86）（中位数差异 52；p < 0.001）。中位（范围）VAS 活动疼痛评分从手术前的 8 分（6 至 9）下降至最近随访时的 2 分（0 至 5）（中位差 -6；p < 0.001）。对于简表 12 项评分，中位（范围）PCS 评分从手术前的 0 分（0 至 30）提高到最近随访时的 70 分（40 至 95）（中位差 70；p < 0.001 ），中位（范围）MCS 评分从手术前的 46 分（21 至 75）提高到最近一次随访时的 75 分（50 至 92）（中位差 29；p < 0.001）。

 结论

采用 Ilizarov 外固定器进行踝关节融合术可能会根除感染并恢复化脓性踝关节炎患者的足部功能。但应充分告知患者与外固定架相关的并发症，如针道感染、反复感染、骨不连等。标准化和专业的针护理非常重要。此外，由于伊利扎洛夫外固定器可能会给患者的日常生活带来不便，未来的研究应该探讨心理支持如何影响使用这些设备进行踝关节融合术的患者。

 证据水平

IV级，治疗研究。